Provider Demographics
NPI:1154760957
Name:KHALILI, VIDA (DC)
Entity type:Individual
Prefix:
First Name:VIDA
Middle Name:
Last Name:KHALILI
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3717 CHEROKEE PLACE
Mailing Address - Street 2:
Mailing Address - City:MARRIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 HEMBREE RD STE 130
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5711
Practice Address - Country:US
Practice Address - Phone:404-671-8499
Practice Address - Fax:404-671-8490
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-14
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO009055111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACHIRO09065OtherLICENSE